ARMD is an aging change or wearing out of the central retina. It causes loss of central vision. This makes reading and driving difficult. Later, if it gets more severe, it becomes difficult seeing faces, crossing roads, and cooking. The peripheral or side vision always remains, so even if the central vision is poor, it is always possible to see and get round the house and see to the side.
Dry ARMD is usually a progressive condition. Invisible early changes occur, with drusen , pigmentary changes, and slight thinning of the retina Later, the dry changes may progress, usually slowly, to cause geographic atrophy and more thinning of central retina. These are all termed part of 'dry' ARMD. There is no tretment for dry ARMD.
A secondary change may then develop in some people, as the body tries to 'heal' the changes. Blood vessels may start to grow in the dmaged centre of the retina in the macula area. The blood vessel growth causes leakage and scarring, and is termed 'wet' ARMD. These wet changes can be slowed down with anti-VEGF eye injections (wet ARMD page).
This page summarises our current knowledge. Age-related macular degeneration is explained in more detail on other
web-sites, such as the RNIB.
An excellent animation: www.eyesight.org.
Contributing factors: aging, genes, diet, smoking,
Age-related macular degeneration (ARMD) is one of the
commonest causes of poor sight in developed countries.
Whilst the causes are different in different
people, certain factors may contribute.
The main factor is age.
"By age 85, 57.4% of [people have] AMD. Age, smoking, plasma HDL cholesterol, BMI, and female sex are associated with AMD. Elevated HDL cholesterol is associated with GA development." .Oph 14
||Age is the main factor.
||Contributes 32% overall, even passive
smoking. BJO 17.
'Just one cigarette a day seriously elevates cardiovascular risk
' BMJ18, so it is best to stop completely.
||related up to ~30%;
a high cholesterol from an unhealthy diet or genes
Klein (2010); Toothbrushing helps. (tooth decay promotes conditions such as rheumatoid arthritis) summary BJO16
||High blood pressure damages the circulation...target is 140 systolic
in clinic, 10 lower for diabetes. 10 lower at home. 120 at home
for diabetes at home. Best
below 120 2
medications often required.
progression to neovascular ARMD by 70% AJO17
||~50% is directly due to the genes we inherit Gene
||a high fat diet 10% (2010)
||This causes cardiovascular
disease, and will contribute to macular disease.
In urban environments, ~8% of deaths are generally attributed to pollution BMJ 14
||Excess alcohol is also related to ARMD, see
||Strong sunlight contributes to ARMD;
and sunglasses protect, see. But gentle sun exposure increases vitamin
D production, and this will reduce the risk of many conditions such as
diabetes, osteoporosis, and prostate cancer. Retina16
CRP, dental caries, each contribute
|| Light skin increases risk Eye 2012.
|obstructive sleep apnoea
||Untreated obstructive sleep apnea hinders response to bevacizumab in age-related macular degeneration Retina 16 BJO 17
||AJO 16 2-4x risk
Some communities in Japan did not develop
macular degeneration as people aged, but as soon as they started eating
Western food the condition started to occur. Similarly, when Japanese
people move to Western countries, they develop the condition more frequently.
These observations suggest that the high fat, and type of fats, such
as saturated and trans-fats, the lack of protective fats
(omega 3s, from fish), and salt (by increasing blood pressure) increases
ARMD. Lack of exercise as we drive everywhere in Western countries will contribute.
We inherit these from our parents.
Genes are the genetic information that tells our body what chemicals
to make. Overall, our genes may contribute to more than 50% of ARMD. The
main genes have been found. Gene page. For example, these genes control the way used-up chemicals
are removed from the eye. Being long-sighted (hyperopic) is also a risk
A healthy lifestyle
A healthy lifestyle helps to prevent
age related macular degeneration. This is important for the younger relations
of age related macular degeneration sufferers:
- Overall smoking accounts
for 32% of ARMD. Even stopping at the age of 80 will reduce the
risk of developing the disease.
So if you have a relation with macular degeneration, try and stop as
smoking may make it develop earlier.
- Smoking increases the risk of macular degeneration about 3 times. Macular
degeneration occurs 10 years earlier in smokers.
- If you have macular degeneration, do try and stop. Even if you are
90 years old stopping smoking will help your eyes considerably.
- Passive smoking is also harmful: for instance, if your partner smokes
cigarettes a day, you receive 25% of the smoke, so that is equivalent
to you smoking 5 cigarettes a day. 28000
cases a year in the UK.
report and 2003
study . Lithuania Japanese China
- Passive smoking doubles the risk , personal smoking triples
the risk of both geographic atrophy and neovascular ARMD.
- Each cigarette increases the ARMD progression rate ~15%.
Blood Pressure & Exercise
- 30 minutes a day at least, walking, or more active
exercise for younger people, reduces
risk by 70%: 2006
- Exercise may help by preventing hardening of the
30 minutes walking a day (regular walking)
three times a week will reduce ARMD risk by one third, compared to people who don't walk or exercise
and who drive everywhere.
- A low blood pressure helps. A level of 140/85 or below is likely
to be best. Blood pressure is written as '140/85', with the systolic/diastolic.
Above 115 (systolic) the risk of heart disease increases. See the evidence and more. Macular
haemorrhages are more likely with high blood pressure. More evidence Eye.
- Obesity is also a risk factor see.
- A low
salt diet is important Salt and more than 2 units of alcohol
a day may cause blood pressure to rise.
Too much may contribute indirectly
by increasing blood pressure, and is related to ARMD, see.
Blood pressure rises after drinking (opposite...drinking 4 pints/bottle
gram of alcohol puts systolic blood pressure up 0.24mmmHg, diastolic
0.16 mmHg. This means 1 pint of beer (2 units, each unit 8g alcohol) with
16gm of alcohol, drunk every day, will put the systolic blood pressure
up (16 x 0.25=) 4mmHg.
Experts recommend a healthy diet.
- This should include a variety of vegetables and fruit,
- 5-9 portions of fruit/vegetables
a day, 100gm portions (2008) see.
- low fat only dairy food
- the minimum of trans and saturated fat Solid fats are harmful Eye 2011
- the minimum of red meat (and no processed meat), as part of a balanced diet
- oily fish ...2
small portions a week, Blue
Mountain 2009, Australia
09 reduces aging Fish and soya contains DHA Retina17
D reduces risk, (Vitamin D increases with sunlight) Archives
- a Mediterranean or
Japanese diet (as was 20years ago) will almost certainly protect.
- plants sterols lower cholesterol food.gov.uk, which foods
- Losing weight (if overweight) reduces risk
BMJ 18 Minimally processed food is prefered (vegetables, fruit, nuts, seeds, beans, vegetables, whole grains, plant oils, live yoghurt): avoid ultraprocessed foods rich in refined starch and sugars, and industrial additives such as trans-fats and salt.
7 portions of vegetables
a day and 2 portins of fruit, with portions of different colours
Fruit/vegetables prevent 36-50% of ARMD see, see and see (fruit & vegetables
lower homocysteine levels, and this improves blood flow) BMJ 15.
Pulses like beans are fine. Bread, pasta, rice and potatoes provide 'energy'.
Vegetarians have lower blood pressures and healthier lipid levels, see .
A healthy diet reduces homocysteine levels, which
are associated with ARMD.
Certainly saturated fats increase the risk of ARMD; and fish and
polyunsaturated fats halve the risk. Avoiding certain fats helps, with
strong evidence here (explained more clearly here for heart
disease). Nuts may help prevent ARMD (small amounts...they are fattening).
Lutein and Zeoxanthin supplements slow down progression on average 10%, AREDS 2, 20% if diet is poor.
2020 As the macula is the most chemically active area in the body, with the greatest oxygen demand, it has been thought that antioxidants such as vitamins may play a critical role.
The retina contains the pigments carotenoids lutein, xeaxanthin, mesoxanthin.
Lutein is in dark green leaves such as kale and spinach, and most of us do not eat enough. Xeaxanthin is in orange peppers, corn, nectarines and oranges (and other yellow/orange fruits/vegetable).
"Higher dietary intake of lutein/zeaxanthin was independently associated with decreased likelihood of having neovascular AMD, geographic atrophy, and large or extensive intermediate drusen" Seddon. No need Cochrane 2017.
Oily fish twice a week reduces ARMD by 40%, especially
oily fish such as tuna, mackerel, sardines, herring, and salmon. A Japanese
diet may be helpful as above. Other omega 3 fats are helpful. See
Cholesterol & statins, patient and relatives
ARMD is commoner in people with higher cholesterol levels.
Atherosclerosis, caused by a high cholesterol, does contribute to ARMD, see . Statin treatment reduces macular degeneration. DK recommends them for people with ARMD. Naturally all relatives of ARMD patients should address this issue
of fat levels in the blood, sticking to a low fat diet with plenty of
exercise, avoiding obesity, just as described on this page for ARMD patients. Statins may not help
Macular pigment density is inversely related to ARMD: the thicker the pigment the less likely the condition.
- this explains why the condition is much commoner in Caucasians with blond hair and lighter coloured retina
- increasing the pigment with lutein may delay the condition Acta 2012 Eye 2012
- ARMD is unusual in Afro-Caribbeans,
and this may be because the 'elastin' layer is thicker.
- Especially in
wet ARMD with CNV, the elastin layer acts as a barrier to the growing
CNV (new vessels). Elastin is part of Bruchs
Cataract surgery and Vitreous changes
One paper suggests cataract
surgery leads to an extra 4-5 times risk of developing
neovascular macular changes or dry ARMD. Another states this is not so AREDS
25. Certainly patients
with early ARMD undergoing cataract surgery should be warned of symptoms,
that is distortion or changes in central vision, and attention should be
sought in a few days. Also.
If the vitreous is separated from
the macular the risk of CNV is significantly reduced AMJO
Wet ARMD (exudative/leaky)
(vascular endothelial growth factor)
blood vessel growth
leakage..blood and fluid
give anti-VEGF drug
leakage stops for a while
In wet ARMD, new vessels grow under the central retina
in the macular area, causing retinal leakage and swelling. (CNV..choroidal neovascularisation). The blood vessel growth seems to be part of the eye's 'healiing' response to ack of oxggen and damage. The damaged retina releases a chemical VEGF (Vascular
endothelial growth factor). The VEGF
stimulates blood vessel growth, to produce the different types of wet
ARMD. In addition, the new blood vessels leak, causing fluid under the
retina in these condition.
The network of blood vessels usually progresses to cause a scar in the macular area. If the scar
is small, sight is reasonable; but if large, the sight can be very poor. It is very difficult to predict whose dry ARMD will progress, but
the risk factors include those mentioned above (soft drusen, high blood
pressure, smoking, poor diet, lack of exercise). This is described below.
There are different types of wet ARMD
'Occult', no PED, = Mixed (predominantly or minimally classic CNV with occult CNV) wet armd
type 1 cnv
In this type of ARMD, there
are new blood vessels, but they are not clearly seen with the angiogram. 'Occult' CNV
is the term given to a specific 'blotchy' appearance of the
angiogram. This is probably an early phase of classic, see .
Occult and classic patterns can occur together. Anti-VEGF drugs generally help. The symptoms of this type of CNV are the same as 'classic
CNV', except the condition takes longer to develop. Without treatment, this usually turns into classic CNV over the next months
or years, to cause poor central vision.
- Large CNV membranes can develop haemorrhages with anti-VEGF treatment
- photo another another..occult/mixed another flash another large diagram
- The term occult is not really used now: the condition is a subtype of wet armd sometimes termed type 1 cnv.
- Sometimes there is a hyper-reflective material which is related to prognosis, and to pachychoroidopathy (= thickened choroid).
- Sometimes there is fluid, but if the fluid is stable injections don't seem to help.
Mixed: classic CNV (formally termed 'classic CNV') wet armd
New vessels growing under the central retina in a 'classic' pattern:
Anti-VEGF treatment needed. enlarge Photo (case 12)
When blood vessels grow under the macula, this is termed choroidal
neovascularisation (CNV). When the new vessels are seen easily on a fluorescein angiogram, they
are called 'classic CNV': they look like a net of blood vessels.
When a doctor looks in the retina looks elevated, there may be tiny
haemorrhages, a grey area, or exudates. Severe . In milder cases vision may still be good. The condition may develop over days or weeks, with increasing distortion
or blurred central vision. If this process is early you can still read,
but if it becomes severe reading with any magnifier is impossible. Treatment is based on anti-VEGF drugs, although other treatment are available
This is usually a serious type of macular degeneration, serious
because it can cause very poor central vision. It never blinds in the sense
that you cannot see light and dark, but in its serious form it can
damage the central vision so you can only see fingers or even the movements
of hands. Once again, the side vision will normally be good, so you
should always be able to walk around the house.
|ARMD progression rate
and relative risk of smoking
CNV vascularised PED =fibrovascular PED and serous PED with neovascularisation wet armd
In this type of CNV there is a PED (pigment epithelial detachment)
PED..pigment epithelial detachment, with CNV (choroidal
neovascularisation): with a PED. This condition usually progresses,
but progression rates are very variable.
In this type of wet ARMD the damaged area looks like a dome, but in addition fluid leaks under
the retina, hence the term 'wet'.
Anti-VEGF drugs generally help. The PED may reduce in size with treatment, and treatment will reduce intraretinal and subretinal fluid. Retina 2011. Occasionally
may 'rip', causing more loss of sight Eye 2011. Overall, 15% of PEDs rip, but the risk is proportional to the PED size, so a large PED is much more likely to rip. About of 8% of patients may develop worse sight with treatment Retina 17. The rip typically occurs 2 months after starting treatment. The rip may not cause that much visual loss initially, but central vision may get worse over time.
November, 7 months later, a PED has developed, with a retinal haemorrhage. Also, intraretinal and subretinal fluid.
Patient, age 86, April, reasonable vision
Photo / OCT show drusen, hard and soft enlarge
A wrinkled PED
This probably represents CNV without subretnal fluid, and needs treatment Retina18:
- treatment should focus on vision gains rather that PED resolution Retina 18. We dont need to elimniate the PED to get the best results.
- ARMD with a PED is classified as CNV, type 1. Outcomes Eye 11
- Look for polyps, see PCV.
- photo case
9 r/l left case.
- There are 3 types of PED, reviewed here (avascular,
- photo avascular PED
- intraretinal cysts indicate a poorer response BJO14; combined with geographic atrophy BJO 14
- treatment helps stabilize/improve SIO 15; fluid fluctuates with injections every 2 months; serous PEDs respond better Retina 16; incomplete response to anti-vegf AJO 16 Variable response Retina 17. Good response Retina 18
- Genetics Retina 20
Retinal angiomatous proliferation: 'RAP'
type 3 CNV, a rap: the choroidal vessels and retinal vessels join up (anastamose)
A RAP (retinal angiomatous proliferation) is a type of wet ARMD. It does not respond as well to antiVEGF treatment as the other types.
- 25% good response Retina17
- mean timme of recurrence was 5 months after the 3rd injection Retina17
- Eye 15
- Retina 16 OCT "subfoveal choroidal thickness <200 μm, presence of intraretinal fluid accumulation, absence of subretinal fluid, gently-sloping dome-shaped retinal pigment epithelial detachment or trapezoid-shaped retinal pigment epithelial detachment without an obvious peak, and intraretinal mass lesion"
- beginning with Retina15 "the earliest sign of Type 3 neovascularization is punctate hyperreflective foci above the external limiting membrane. The mature Type 3 lesions and associated serous pigment epithelial detachments are highly responsive to anti-vascular endothelial growth factor therapy"
- During treatment 5% of patients developl submacular haemorhages, and 5% rips Retina18
a dome is shown on the OCT...fluid, enlarge, and there is exudate and a small haemorrhage enlarge.
This is another type of CNV. The condition is seen as a branching choroidal network of vessels with vascular dilatation.
PEDs are present in different types of ARMD, but the caues are slighty different. The treatment depends on the cause. The PED is a dome of fluid under the pigment layer of the retina.
This is another type of PED, without any vascular element. In younger
patients this is usually part of Central Serous
Retinopathy. In older patients this is usually part of 'dry' ARMD, and
there may have been obvious 'dry' changes visible before this develops. Anti-VEGF treatment is not helpful (Eye
2010). Perhaps a serous PED in an older patient is better thought of as half way between dry and wet ARMD.
However, if the other eye has had wet ARMD, then such an eye is at very high risk of wet ARMD itself. Eye 2012 . It is probably safer for such a patient to have regular OCT examinations, perhaps every 3 months: as yet there is no evidence to prove that this will help, but logically it will help by detecting very early disease that is much easier to treat.
How would you know if you have the 'neovascular' type of age related
macular degeneration? Some symptoms suggest you may be developing the problem:
If you do develop distortion of vision you usually need to see your
optometrist and have an OCT scan within a few days. See the amsler test below. Your optmerist or ophthalmologist will recommend an OCT scan, and this shows the wet ARMD immediately.
Wet ARMD progresses 4 times faster (a 400% increase in progression
rate) in smokers.
Dry ARMD may develop into 'wet' ARMD (4%/year).
In wet ARMD, leaks develop,
and new vessels start to grow right through the retina.
Occasionally wet ARMD develops without dry changes, although usually
there is an area of retinal damage that triggers the process. photos
There may be a trigger factor such as inflammation, that triggers the conversion of dry to wet. (For example. teeth decay bacteria have been implicated.)
should be given the Amsler Grid test to use every day, or at
least once a week, at home. These
authors recommend this test, although personally I have found that
patients may still present late (this is a major problem). Patients are given a grid, told to look at the central spot with their
reading glasses on, using one eye at a time. If any of the adjacent
lines become bent or wiggly or distorted, then CNV (blood vessels growing
under the macula) may be present, and patients should see their optometrist, ophthalmologist
(or in Birmingham attend the Eye Centre Casualty, City Hospital). The test is explained well here . home device another Ophth14
Unfortunately age related macular
degeneration can affect the other eye. See healthy
lifestyle above: this may help. If you do notice a change in your sight,
see distortion above. Risk
Many types of macular degeneration progress to cause scarring. 'Dry'
types usually progress more slowly, but occasionally can cause very
poor central vision, but this is commoner in the 'wet types'.
Sometimes retina in the macula area can tear and shrink. This
is call a 'rip' or a 'tear' of the pigment epithelium. It may occur spontaneously
as part of wet ARMD, but can occur after PDT or anti-VEGF treatment, particularly if there is a large PED.
A rip may cause significant loss of central vision see. but the risks are only slightly
Here is a summary of some of the abbreviations ophthalmologists use
in this condition:
|anti-VEGF / injection
||drugs that reduce growth and leaking from the new blood vessels under the retina in ARMD, or on the retina in diabetes etc. They are given by injection into the eye. Avastin, Lucentis, Eyela.
||age-related macular disease = age-related macular degeneration = ARMD
||age-related macular degeneration
||easy-to-see neovascular ARMD (based
on angiogram) blood vessels growing under the retina and leaking
||choroidal new vessels (i.e. neovascular
macular degeneration, or 'wet'). Blood vessels growing through the retina
under the macula.
Also called CCNV.
|CNVM or CNVm
||a choroidal neovascular membrane, that is a network of CNV,
although in practice this means the same thing as CNV
||central serous chorio-retinopathy
||a type of aging change of the retina...tiny white spots/areas
||thinning (and other changes)
of the central retina
||the very centre of the macula
||indocyanine green angiography
||intraretinal fluid (an OCT scan finding)
||the centre of the retina that sees detailed vision like faces and reading
||similar meaning to wet armd
|OCT / scans
||optical coherence tomogram: a 3 dimensional photograph of the macula, called a scan
||hard-to-see neovascular ARMD (based
blood vessels growing under the retina and leaking (but the leakage is late) (type 1 CNV)
||Polypoidal choroidal vasculopathy
therapy (for classic sub-foveal neovascular ARMD )
||pigment epithelial detachment,
a type of wet ARMD
||retinal angiomatous proliferation (type 3 cnv)
||a pigment epithelial rip or tear
||subretinal fluid (not subretinal fibrosis)
||fluid under the retina typically type 2 cnv (or part of other types)
||Vascular endothelial growth factor...the main chemical that
makes blood vessels grow in ARMD
||Virtual macular clinic..patients attend for an OCT and the scan is interpreted later, and the patient contact if another anti-vegf injection is needed
||wet age-related macular degeneration, with CNV as above (blood vessels growing and leaking under the retina, usually under the macula)